Method for reducing flu-like symptoms associated with intramuscular administration of interferon using a fast titration escalating dosing regimen

ABSTRACT

A combination and method for treating multiple sclerosis (MS), and for reducing flu-like symptoms associated with administration of an interferon to a patient with MS. The method involves intramuscularly administering the interferon to the MS patient according to an escalating dosing regimen in weeks 1 to 3, and a full therapeutically effective dose of interferon in week 4. In one embodiment of the invention, the escalating dosing regimen comprises administering one quarter of the therapeutically effective dose in week 1, half of the therapeutically effective dose in week 2, and three-quarters of the therapeutically effective dose in week 3. Also provided are titration packages for enabling compliance with a regimen of changing dosage of an interferon over a period of time.

CROSS REFERENCE TO RELATED APPLICATION(S)

This application is a continuation of U.S. patent application Ser. No.16/660,038, filed Oct. 22, 2019, which is a continuation of U.S. patentapplication Ser. No. 15/695,587, filed Sep. 5, 2017, now U.S. Pat. No.10,500,254, issued on Dec. 10, 2019, which is a continuation of U.S.patent application Ser. No. 14/936,228, filed Nov. 9, 2015, nowabandoned, which in turn is a division of U.S. patent application Ser.No. 13/421,197, filed Mar. 15, 2012, now U.S. Pat. No. 9,198,955, issuedon Dec. 1, 2015, which in turn claims priority benefit of U.S.provisional patent application Ser. No. 61/476,930, filed Apr. 19, 2011,and 61/452,807, filed Mar. 15, 2011. The disclosure of each applicationand patent is incorporated herein in its entirety by reference.

BACKGROUND OF THE INVENTION Field of the Invention

The present invention relates generally to a method for treatingmultiple sclerosis (MS), and for reducing flu-like symptoms generallyassociated with administration of interferons. In particular, the methoduses a fast-titration escalating dosing regimen of intramuscularlyadministered interferon. The invention also relates to titrationpackaging to promote compliance with the dosage titration.

Description of Related Art

Multiple sclerosis (MS) is a chronic neurological and inflammatorydisorder of the central nervous system, marked by focal autoreactiveT-cell and macrophage infiltration through the blood brain barrier thatlead to demyelination, and axonal and neuronal loss. In people affectedby MS, patches of damage called plaques or lesions appear in seeminglyrandom areas of the CNS white matter. At the site of a lesion, a nerveinsulating material, myelin, is lost in demyelination. Inflammation,demyelination, oligodendrocyte death, membrane damage and axonal deathall contribute to the symptoms of MS.

Although MS has an unknown etiology, the classical hypothesis is that MSis a T helper 1 (TH1)-cell mediated autoimmune disease. Development oflesions is characterized by accumulation of activated microglia andmacrophages. Acute plaques are characterized by blood brain barrierdamage, infiltration by activated CD4+ T cells and clonotypic CD8+ Tcells that recognize CNS autoantigens, and the presence of reactiveastrocytes and proliferating oligodendrocytes. Pro-inflammatorycytokines, e.g. interleukin 12 (IL-12) and tumour-necrosis factor-a(TNF-a), are also present. There is further evidence that other adaptiveimmune cells (e.g. TH17 cells and peripheral B lymphocytes) and innateimmune cells (dendritic cells, natural killer T cells and residentmicroglia) play a role in MS pathogenesis.

Relapse-remitting MS, the most common form of the disease, ischaracterized by multiple exacerbations over time. Exacerbations areattacks on vision, motor, sensory, and sphincter control and cognitiveprocesses. Patients with relapse-remitting MS do not completely recoverfrom these exacerbations and accrue neurologic disability with eachsubsequent exacerbation.

Natural human fibroblast interferon-beta (IFN-β) was the first drug totreat relapse-remitting MS. IFN-β has immunomodulatory effects, whichinclude modulating cytokine levels (e.g., inducing Th1 (T-helper 1)related cytokines and Th2 related cytokines), inhibiting T-cellactivation and proliferation, inhibiting transmigration of autoreactiveT cells into the CNS, increasing T cell apoptosis, and reducingexpression of molecules required for antigen presentation. IFN-β haswell-established clinical effects and studies evidence that IFN-β worksagainst multiple sclerosis through immunomodulation.

There are currently two different recombinant interferon-beta treatmentsfor MS: interferon beta-1α (IFN-β_(1a)) and interferon beta-1b(IFN-β_(1b)). IFN-β_(1a) and IFN-β_(1b) are two distinct molecules withdifferent recommended dosages, routes of administration and dosingintervals. IFN-β_(1a) is a 166 amino acid glycoprotein with a predictedmolecular weight of approximately 22,500 daltons. It is produced byrecombinant DNA technology using genetically engineered Chinese HamsterOvary cells into which the human interferon beta gene has beenintroduced. The amino acid sequence is identical to that of naturalhuman interferon beta. IFN-β_(1b) has 165 amino acids and an approximatemolecular weight of 18,500 daltons. It does not include the carbohydrateside chains found in the natural material. IFN-β_(1b) is manufactured bybacterial fermentation of a strain of Escherichia coli that bears agenetically engineered plasmid containing the gene for human interferonbeta_(ser17). The specific activity of IFN-β_(1a) and IFN-β_(1b) aredifferent and based on different World Health Organization (WHO)reference standards of recombinant interferon beta and different assaysused to measure activity.

Current IFN-β_(1a) treatments include Avonex®, CinnoVex™, Rebif®, andResigene. Current IFN-β_(1b) treatments include Betaseron® in the US andBetaferon® in Europe, and Extavia®. Avonex® and CinnoVex™ areadministered intramuscularly, while the other interferon treatments forMS are administered subcutaneously.

Although there is a difference in specific activity between the twotypes of interferons, IFN-β_(1a) and IFN-β_(1b) share similar sideeffect profiles. For example, a common adverse event associated withinterferon therapies are flu-like symptoms that develop within a fewhours after administration and subside within 24 hours. Flu-likesymptoms associated with administration of interferons include fever,muscle aches (myalgia), chills, sweating, fatigue, headache, andmalaise. The exact mechanism for the development of flu-like symptoms isnot well understood but occurs among patients taking interferonsirrespective of disease state. It has been postulated that interferonsstimulate the sub-thalamic nucleus, thus affecting temperature, as wellas local cytokines resulting in other symptoms.

Generally, the flu-like symptoms will significantly decrease after 2-3months. However, flu-like symptoms associated with interferonadministration at the beginning of treatment can be a significantbarrier to the initiation or maintenance of MS therapy, even before theonset of any therapeutic benefit. Use of an escalating dosing regimen(also known as dose titration) has become a routine practice for theadministration of interferon therapies to manage side effects at theinitiation of therapy. The goal of dose titration is to improve theacceptance and adherence of therapy and, thus, impact long-term healthbenefits for patients with multiple sclerosis. Currently, there are onlytwo interferon-beta products, Betaseron® and Rebif®, that provide dosetitration instructions in their labels. Both Betaseron® and Rebif® areadministered subcutaneously.

The Betaseron® (10/07) label includes titration instructions forsubcutaneous administration of IFN-β_(1b) over a six-week period, withfull dose beginning in week 7:

Weeks 1-2—¼ of a dose (0.0625 mg/0.25 ml)

Weeks 3-4—½ of a dose (0.125 mg/0.5 ml)

Weeks 5-6—¾ of a dose (0.1875 mg/0.75 ml)

Week 7— full dose (0.25 mg/1 ml)

The Betaseron® label indicates dose titration may reduce flu-likesymptoms. The European Betaferon® label (1-8-24) includes titrationinstructions for subcutaneous administration over a three week period,with full dose beginning in week 4:

Week 1—¼ of a dose (0.0625 mg/0.25 ml)

Week 2—½ of a dose (0.125 mg/0.5 ml)

Week 3—¾ of a dose (0.1875 mg/0.75 ml)

Week 4—full dose (0.25 mg/1 ml)

Although the European Betaferon® label has a three week titration periodwith ¼ dose increments, the label recommends dose titration at the startof treatment in order to increase tolerability and to reduce sideeffects, only generally, at the start of therapy. Unlike the USBetaseron® label which indicates a 6 week titration period and thepossibility of a reduction in flu-like symptoms, the 3 week titrationperiod of the European Betaferon® label is silent with respect totreating flu-like symptoms. Two clinical studies reveal that ¼ doseincrements over a three-week period do not provide a significantreduction in flu-like symptoms in comparison to slow titration regimens.

Rice et al (Rice G P A, Ebers G C, Lublin F D, Knobler R L. IbuprofenTreatment versus Gradual Introduction of Interferon beta-1b in Patientswith MS. Neurology 52:1893-1895, 1999) evaluated the effectiveness ofdose titration in combination with ibuprofen in reducing the flu-likeside effects of Betaseron® administered subcutaneously in 49 patientswith Relapsing-Remitting and Secondary Progressive Multiple Sclerosis(RR and SPMS). This was a randomized, open-label, study that comparedpatients who did not titrate Betaseron® but took ibuprofen prophylaxis(Group A), to those who titrated Betaseron® with (Group B) and withoutIbuprofen treatment (Group C). Group A received 8 million IU (MIU) ofBetaseron® every second day (the standard dose) during weeks 0-4. GroupsB and C each received Betaseron® according to the titration schedulestarting at 2 MIU (25% of the standard dose) and increased at incrementsof 2 MIU (25% of the standard dose) during weeks 0-4. During weeks 0-4,11% (2 out of 18) of Group A patients developed flu-like symptoms, 6% (1out of 6) of Group B patients developed flu-like symptoms, and 40% ofGroup C patients developed flu-like symptoms (Table 1 of Rice et al.).The differences in incidence of flu-like symptoms between the groupreceiving ibuprofen treatment alone (Group A) and the group receivingdosage escalation and ibuprofen treatment (Group B) does not appear tobe significant.

Moreover, Rice et al. reported that 5 (three from Group A, one fromGroup B, and one from Group C) of the 49 patients (10%) in the studyexperienced difficulty while escalating the dose of IFN-β_(1b), andthese patients required either dosage reduction or a delay in theescalating schedule.

This was common practice according to Bayas et al. (Bayas A andRieckmann P. Managing the Adverse Effects of Interferon-β Therapy inMultiple Sclerosis. Drug Safety 22(2):149-159, 2000). Bayas et al.described dose titration for administration of IFN-β_(1b) (which is onlyadministered subcutaneously) where treatment began at 20 to 25% dose for1 week, increased to 50% dose the second week, and if treatment wastolerated, increased to full dose. According to Bayas et al.,interferon-β dosage should be reduced or kept at the same level for alonger time until improved drug tolerability allows an increase. Waltheret al. (Walther E U, Hohlfeld R. Multiple Sclerosis Side Effects ofInterferon beta Therapy and their Management. Neurology 53:1622-1627,1999) recommended one dose reduction (between 25-50%) that should bemaintained, rather than escalated, for 4-6 weeks. Thus, it was commonpractice to err on the side of an extended titration schedule.

Wroe (Wroe S J. Effects of dose titration on tolerability and efficacyof interferon beta-1b in people with multiple sclerosis. J Int Med Res33:309-18, 2005) evaluated whether a slower, four-stage, 4 weektitration to a final dose of 250 μg subcutaneous IFN-β_(1b) mightimprove tolerability over a more rapid two-stage, 2 week titration inpatients with relapsing-remitting MS over a 3-month period. In theslow-titration group, IFN-β_(1b) was subcutaneously administered,initially at 62.5 μg (¼ dose) every other day for 9 days, and then at ¼dose increments (125 μg and 187.5 μg, respectively) on days 11 and 21,and a full dose (250 μg) beginning on day 31 (i.e. in the middle of week5) for the remainder of the 3-month treatment. See FIG. 1 of Wroe et al.In the fast-titration group, IFN-β_(1b) was subcutaneously administered,initially at 125 μg (½ dose) every other day for 2 weeks and then atfull dose for the remainder of the 3-month treatment. One of the primaryadverse events assessed was flu-like symptoms. Wroe reported nonoticeable differences with respect to the occurrence of adverse eventsbetween the two treatment groups, e.g., the incidence rates of flu-likesymptoms were similar in the slow—(32.4%) and rapid titration (41.9%)groups (FIG. 3 of Wroe et al). Wroe concluded that a rapid-titrationregimen (½ dose increments, with a full dose beginning in week 3)results in a quicker onset of clinical benefit and slow titration (¼dose increments, with a full dose beginning in the middle of week 5)showed a non-significant reduction in flu-like symptoms compared to therapid-titration regimen.

The Rebif® label includes titration instructions for subcutaneousadministration of IFN-β_(1a) three times per week over a 4-week period,with full dose administered in week 5:

Weeks 1-2—⅕ of a dose-subcutaneous injection 3×/week

-   -   (titration dose for 33 μg=4.4 μg)    -   (titration dose for 44 μg=8.8 μg)

Week 3-4—½ of a dose—subcutaneous injection 3×/week

-   -   (titration dose for 33 μg=11 μg)    -   (titration dose for 44 μg=22 μg)

Week 5—full dose—subcutaneous injection 3×/week

The European Rebif® label recommends a gradual increase during a 4 weekperiod to reduce adverse reactions. The ⅕ dose during the first twoweeks serves the purpose of allowing tachyphylaxis to develop, thusreducing side effects. Both the US and European labels are silent withrespect to treating flu-like symptoms associated with administration ofinterferon-beta. All of the products and clinical studies discussed thusfar relate to subcutaneous administration of IFN-β_(1a) or IFN-β_(1b).

Brandes et al. (Brandes D W, Bigley K, Hornstein W, Cohen H, Au W,Shubin R. Alleviating Flulike Symptoms with Dose Titration andAnalgesics in MS Patients on Intramuscular Interferon beta-1a Therapy: apilot study. Curr Med Research and Opinions 23(7):1667-1672, 2007),appears to be the first to investigate dose titration of intramuscularadministration (IM) of IFN-β_(1a). Brandes et al. evaluated theeffectiveness of dose titration in combination with acetaminophen oribuprofen in reducing the flu-like side effects of Avonex® (IFN-β_(1a))in 47 patients with relapsing-remitting multiple sclerosis.

The Brandes et al. study was a multi-site, randomized, open-label,12-week study. Group 1 patients received (IM) IFN-β_(1a) at a dose of 30μg once weekly with no titration. Groups 2 and 3 received (IM)IFN-β_(1a) at ¼ dose during weeks 1 and 2, ½ dose for weeks 3 and 4, ¾dose at weeks 5 and 6, and a full dose (30 μg) for weeks 7-12. Groups 1and 2 received acetaminophen 650 mg 1 hour before each (IM) IFN-β_(1a)injection, then every 4 hours as needed. Group 3 received ibuprofen 400mg 1 hour before each (IM) IFN-β_(1a) injection, again at 6 hoursfollowing injection, then every 6 hours as needed. Flu-like symptomswere recorded at three time points: baseline (first dose of analgesic, 1hour pre-injection); Time A (second dose of analgesic, 4 hourspost-injection); and Time B (12-15 hours post-injection).

Brandes et al. found that one-quarter titration (Groups 2 and 3)significantly reduced the proportion of patients with a mean increase of≥2 from baseline in flu-like symptom score compared with no titrationonly at 4 hours post-injection during the first two weeks (FIG. 1A ofBrandes et al., p=0.015 indicated with *). There was no significantdifference between the one-quarter titration (Groups 2 and 3) and notitration (Group 1) at 4 hours during weeks 3-12 as the dose wasincreased. These data suggested that a ¼ dose escalation does not reduceflu-like symptoms, suggesting that further prolonged titration, i.e., aneven slower titration, would be necessary.

Also, there was no significant difference between the one-quartertitration (Groups 2 and 3) and no titration (Group 1) at 12-15 hoursduring any week, including the first two weeks. These data suggestedthat initiating (IM) IFN-β_(1a) injection with a 1/4 dose had limitedeffects in reducing flu-like symptoms because the ¼ dose only delayedthe onset of flu-like symptoms and only did so during the first twoweeks.

Frohman et al (Frohman E et al. Disease-Modifying Therapy in MultipleSclerosis: Strategies for Optimizing Management. Neurologist 8:227-236,2002) in a comprehensive review of MS therapy management, recommendsinitiating treatment during the tapering phase of a steroid regimen andapplying a fractionated dosing scheme in patients treated with eitherAvonex®, Rebif® or Betaseron® in combination with a nonsteroidalanti-inflammatory agent. In particular, patients were started at 25% ofthe recommended dose and dosages were increased by 25% increments weeklyto every other week. Frohman et al. describes the 25% dose as “a doseusually associated with minimal to no side effects” given thatinterferon-related side effects are dose-response related.Significantly, Frohman et al. states, “If patients experience severe andlimiting side effects as the dose is increased, we will generallyprolong titration, escalating by the same increment every 2 to 4 weeks.With this approach, we have had very few patients fail drug initiation.”Thus, Frohman teaches to err on the side of an extended titrationschedule.

It is therefore desirable to provide a method for further reducingflu-like symptoms associated with intramuscular interferonadministration, which will promote compliance and continuation ofinterferon therapy for MS.

SUMMARY OF THE INVENTION

The inventors have surprisingly found that by decreasing the time periodof the dose titration schedule for the intramuscular administration ofinterferon (“fast titration”), the appearance of flu-like symptoms issignificantly reduced as compared to a longer dose titration schedule(“slow titration”).

As such, the present invention provides a method for treating multiplesclerosis, which includes intramuscularly administering an interferon toa patient once per week, and specifically includes an initial titrationperiod wherein the interferon is administered in an escalating doseregimen (a “titration period”). In particular, the titration periodincludes a one-quarter dose in week one, a one-half dose in week two, athree-quarter dose in week 3, and a full therapeutically effective dosein week 4 and thereafter.

The present invention also provides a method for reducing flu-likesymptoms associated with the administration of an interferon to apatient with multiple sclerosis, including (a) intramuscularlyadministering the interferon to the patient according to an escalatingdosing regimen in weeks 1 to 3; and (b) intramuscularly administering afull therapeutically effective dose of interferon in week 4.

The invention also relates to a titration package for enablingcompliance with these methods, wherein the dosage of interferon changesover a period of time. The titration package includes interferondelivery devices containing an interferon, and instructions for thepatient to administer the interferon in an escalating dose regimenduring a titration period.

The foregoing and other objects, features and advantages of theinvention will be apparent from the following more particulardescription of preferred embodiments of the invention.

BRIEF DESCRIPTION OF THE FIGURES

The accompanying Figures, which are incorporated herein and form part ofthe specification, illustrate embodiments of the present invention and,together with the description, further serve to explain the principlesof the invention.

FIG. 1 is a flow chart showing the design of a “fast vs. slow” titrationtrial. Note that in the Example below, additional subjects wereinvestigated.

FIG. 2 is a table with the titration schedules in a clinical study.Patients in Treatment Group 1 received a full intramuscular dose ofAvonex® each week for 8 weeks. Patients in Treatment Group 2 receivedintramuscular doses of Avonex® according to a fast titration schedule (¼dose in week 1, ½ dose in week 2, ¾ dose in week 3, and full dose inweeks 4-8). Patients in Treatment Group 3 received intramuscular dosesof Avonex® according to a slow titration schedule (¼ dose in weeks 1-2,½ dose in weeks 3-4, ¾ dose in weeks 5-6, and full dose in weeks 7-8).All patient groups received prophylactic medication.

FIG. 3 describes a method of scoring flu-like symptoms (FLS) inaccordance with the invention.

FIG. 4 is a line graph of the primary outcome variable and shows thechange in total flu-like symptom (FLS) score from pre-injection to 4 to6 hours after injection over 8 weeks.

FIG. 5 is a line graph of the secondary outcomes variable and shows thechange in total flu-like symptom (FLS) score from pre-injection to 12 to15 hours after injection over 8 weeks.

FIG. 6 is a table of the secondary outcome variable and provides theodds ratio of incidence of flu-like symptom (FLS) score at 4 to 6 hoursand at 12 to 15 hours after injection over 8 weeks.

FIG. 7 provides data comparing the effect on flu-like symptoms of notitration, fast titration and slow titration.

FIG. 8 is a bar graph comparing the change in flu-like symptoms (FLS) at4-6 hours, comparing no titration to fast titration.

FIG. 9 provides data comparing the effect on flu-like symptoms of notitration to slow titration.

DETAILED DESCRIPTION OF THE INVENTION

The invention provides a method for treating a subject with multiplesclerosis, by intramuscularly administering an interferon using aninitial escalating dosage regimen or titration period. Treatment ispreferably once a week. The escalating dosage regimen typically involvesadministration of a one-quarter dose in week one, a one-half dose inweek two, a three-quarter dose in week 3, and a full therapeuticallyeffective dose in week 4 and thereafter.

In a preferred embodiment, the week one dose is about 7.5 micrograms,the week two dose is about 15 micrograms, the week three dose is about22.5 micrograms, and the week four dose is about 30 micrograms.

In a preferred embodiment, the interferon is interferon β. In a morepreferred embodiment, the interferon is an interferon β₁. In a mostpreferred embodiment, the interferon is interferon β_(1a).

The invention also provides a method for reducing the flu-like symptomswhich can accompany the intramuscular administration of an interferon.In particular, the invention provides a method involving theintramuscularly administration of interferon to the patient according toan escalating dosing regimen in weeks 1 to 3; and then theadministration of a full therapeutically effective dose of interferon inweek 4.

Reducing flu-like symptoms can be measured in reduction of severity ofsymptoms, and/or reduction in incidence of flu-like symptoms. Thereduction can be measured at various timepoints post-injection, forexample 4 to 6 hours post-injection and 12 to 15 hours post-injection.

Preferably, the reduction in severity of flu-like symptoms at 4 to 6hours is at least 40%, more preferably at least 50%, even morepreferably at least 60%, and most preferably at least 70%. The reductionin severity of flu-like symptoms at 12 to 15 hours is preferably atleast 10%, more preferably at least 20%, even more preferably at least25%, and most preferably at least 30%.

The reduction in incidence of flu-like symptoms at 4 to 6 hours ispreferably at least 5%, more preferably at least 10%, even morepreferably at least 15%, and most preferably about 20%. Preferably, thereduction in incidence of flu-like symptoms at 12 to 15 hours is atleast 10%, more preferably at least 15%, even more preferably at least20%, and most preferably about 25%.

In a preferred embodiment, the invention includes administering onequarter of the therapeutically effective dose in week 1, half of thetherapeutically effective dose in week 2, and three-quarters of the fulltherapeutically effective dose in week 3.

In a most preferred embodiment, the full therapeutically effective doseis 30 micrograms.

Flu-like symptoms can include, for example, fever, muscle aches(myalgia), chills, sweating, fatigue, headache, and malaise, and can bescored in accordance with the method of FIG. 3.

The methods of the invention can further include the administration ofan analgesic or anti-inflammatory drug, or a mixture thereof. The drugmay be a steroid or a non-steroidal anti-inflammatory drug. Preferreddrugs include acetaminophen and ibuprofen.

The invention also provides titration packages, wherein the interferonis presented in a way to promote compliance with the escalating dosageregimen, and ultimately the long-term treatment using the interferon.

In a preferred embodiment, the package includes interferon and deliverydevices for the interferon. The interferon may be in lyophilized form,and thus packaged in a jar or vial. In this case, the package alsopreferably contains a device, such as a syringe, which is pre-filledwith a diluent for lyophilized interferon.

Alternatively, the interferon may in liquid form. In this case, theinterferon may be provided in pre-filled syringes. The syringes may beprovided with the exact dosage for weeks 1-4 and thereafter.Alternatively, an accessory to the delivery device may also be provided,which when used in combination with the syringe, is capable of titratingthe correct volume or dosage for the particular week of the escalatingdosage regimen (titration period).

Where the interferon is provided in a syringe, the syringe may also beprovided with a needle stick prevention device. Such a prevention devicecan include a needle shield, which may be automated. The shield may becompletely automatic (i.e., without any action by the patient), or maybe activated by the patient.

The interferon may also be provided in other delivery devices, such as apen.

The titration package also preferably contains instructions forintramuscular administration of the interferon by a patient during atitration period, wherein the interferon is preferably administered at aone-quarter dose in week one, a one-half dose in week two, athree-quarter dose in week 3, and a full therapeutically effective dosein week 4.

The following terms are used herein:

Interferon—An “interferon” (also referred to as “IFN”) is a small,species-specific, single chain polypeptide, produced by mammalian cellsin response to exposure to a variety of inducers such as viruses,polypeptides, mitogens and the like. The most preferred interferon usedin the invention is glycosylated, human, interferon-β that isglycosylated at residue 80 (Asn 80) and that is preferably derived viarecombinant DNA technologies. This preferred glycosylated interferon-βis called “interferon-β_(1a)”. The term “interferon-β_(1a)” is alsointended to encompass all mutant forms (i.e., Example 1) provided thatthe mutants are also glycosylated at the Asn 80 residue.

Recombinant DNA methods for producing proteins are known.

Preferred interferon-β_(1a) polynucleotides that may be used in thepresent methods of the invention are derived from the wild-typeinterferon β gene sequences of various vertebrates, preferably mammalsand are obtained using methods that are well-known to those havingordinary skill in the art such as the methods described in the followingU.S. patents: U.S. Pat. No. 5,641,656 (issued Jun. 24, 1997: DNAencoding avian type I interferon proprotein and mature avian type Iinterferon), U.S. Pat. No. 5,605,688 (Feb. 25, 1997-recombinant dog andhorse type I interferons); U.S. Pat. No. 5,231,176 (Jul. 27, 1993, DNAmolecule encoding a human leukocyte interferon)); U.S. Pat. No.5,071,761 (Dec. 10, 1991, DNA sequence coding for sub-sequences of humanlymphoblastoid interferons LyIFN-alpha-2 and LyIFN-alpha-3); U.S. Pat.No. 4,970,161 (Nov. 13, 1990, DNA sequence coding for humaninterferon-gamma); U.S. Pat. No. 4,738,931 (Apr. 19, 1988, DNAcontaining a human interferon beta gene); U.S. Pat. No. 4,695,543 (Sep.22, 1987, human alpha-interferon Gx-1 gene and U.S. Pat. No. 4,456,748(Jun. 26, 1984, DNA encoding sub-sequences of different, naturally,occurring leukocyte interferons).

Mutants of interferon-β_(1a) may be used in accordance with thisinvention. Mutations are developed using conventional methods ofdirected mutagenesis, known to those of ordinary skill in the art.Moreover, the invention provides for functionally equivalentinterferon-β_(1a) polynucleotides that encode for functionallyequivalent interferon-beta-1a polypeptides.

In summary, the term “interferon” includes, but is not limited to, theagents listed above as well as their functional equivalents. As usedherein, the term “functional equivalent” therefore refers to aninterferon-β_(1a) protein or a polynucleotide encoding theinterferon-beta-1a protein that has the same or an improved beneficialeffect on the mammalian recipient as the interferon of which it isdeemed a functional equivalent. As will be appreciated by one ofordinary skill in the art, a functionally equivalent protein can beproduced by recombinant techniques, e.g., by expressing a “functionallyequivalent DNA”. Accordingly, the instant invention embracesinterferon-β_(1a) proteins encoded by naturally-occurring DNAs, as wellas by non-naturally-occurring DNAs which encode the same protein asencoded by the naturally-occurring DNA. Due to the degeneracy of thenucleotide coding sequences, other polynucleotides may be used to encodeinterferon-β_(1a). These include all, or portions of the above sequenceswhich are altered by the substitution of different codons that encodethe same amino acid residue within the sequence, thus producing a silentchange. Such altered sequences are regarded as equivalents of thesesequences. For example, Phe (F) is coded for by two codons, TTC or TTT,Tyr (Y) is coded for by TAC or TAT and His (H) is coded for by CAC orCAT. On the other hand, Trp (W) is coded for by a single codon, TGG.Accordingly, it will be appreciated that for a given DNA sequenceencoding a particular interferon there will be many DNA degeneratesequences that will code for it.

The interferon may be administered per se as well as in the form ofpharmaceutically acceptable esters, salts, and other physiologicallyfunctional derivatives thereof. In such pharmaceutical and medicamentformulations, the interferon preferably is utilized together with one ormore pharmaceutically acceptable carrier(s) and optionally any othertherapeutic ingredients. The carrier(s) must be pharmaceuticallyacceptable in the sense of being compatible with the other ingredientsof the formulation and not unduly deleterious to the recipient thereof.The interferon is provided in an amount effective to achieve the desiredpharmacological effect, as described above, and in a quantityappropriate to achieve the desired daily dose.

The formulations include those suitable for intramuscularadministration.

The formulations may conveniently be presented in unit dosage forms andmay be prepared by any of the methods well known in the art of pharmacy.Such methods generally include the step of bringing the activeingredient(s) into association with a carrier which constitutes one ormore accessory ingredients. Typically, the formulations are prepared byuniformly and intimately bringing the active ingredient(s) intoassociation with a liquid carrier.

The formulations may be presented in unit-dose or multi-dose form.

In addition to the aforementioned ingredients, the formulations mayfurther include one or more accessory ingredient(s) selected fromdiluents, buffers, disintegrants, surface active agents, thickeners,lubricants, preservatives (including antioxidants), and the like.

In yet more detail, the present invention is described by the followingitems which represent additional embodiments hereof.

1. A method for treating multiple sclerosis, including intramuscularlyadministering an interferon to a patient once per week, whereintreatment begins with a titration period wherein the interferon isadministered at a one-quarter dose in week one, a one-half dose in weektwo, a three-quarter dose in week 3, and a full therapeuticallyeffective dose in week 4 and thereafter.

2. The method of item 1, wherein the week one dose is about 7.5micrograms, the week two dose is about 15 micrograms, the week threedose is about 22.5 micrograms, and the week four dose is about 30micrograms.

3. The method of item 1, wherein the interferon is interferon β_(1a).

4. A method for reducing flu-like symptoms associated withadministration of an interferon to a patient with multiple sclerosis,including:

(a) intramuscularly administering the interferon to the patientaccording to an escalating dosing regimen in weeks 1 to 3; and

(b) intramuscularly administering a full therapeutically effective doseof interferon in week 4.

5. The method of item 4, wherein the escalating dosing regimen comprisesadministering one quarter of the therapeutically effective dose in week1, half of the therapeutically effective dose in week 2, andthree-quarters of the therapeutically effective dose in week 3.

6. The method of item 4, wherein the interferon is interferon β_(1a).

7. The method of item 4, wherein the full therapeutically effective doseis 30 micrograms.

8. The method of item 4, wherein the flu-like symptoms include fever,muscle aches, chills, sweating, fatigue, headache, and malaise.

9. A titration package for enabling compliance with a regimen ofchanging dosage of an interferon over a period of time, the packageincluding interferon delivery devices containing an interferon andinstructions for administration by a patient during a titration period,wherein the interferon is administered at a one-quarter dose in weekone, a one-half dose in week two, a three-quarter dose in week 3, and afull therapeutically effective dose in week 4.

10. The titration package of item 9, wherein the instructions indicate aweek one dosage of about 7.5 micrograms, a week two dose of about 15micrograms, a week three dosage of about 22.5 micrograms, and a weekfour dosage of about 30 micrograms.

11. The titration package of item 9, wherein the interferon is providedin a vial in lyophilized form.

12. The titration package of item 11, further comprising a vial adapterand a syringe pre-filled with a diluent for said lyophilized interferon.

13. The titration package of item 9, wherein the interferon is providedin a liquid formulation.

14. The titration package of item 13, wherein the liquid interferonformulation is provided in pre-filled syringes.

15. The titration package of item 14, wherein the pre-filled syringesare filled with a correct dosage for weeks one to four.

16. The titration package of item 9, wherein the delivery devicecomprises an auto-injector.

17. The titration package of item 9, wherein the delivery device isneedle-free.

18. The titration package of item 9, wherein the deliver device is apen.

19. The titration package of item 9, further comprising a needle stickprevention device.

20. The titration package of item 19, wherein the needle-stickprevention device includes a needle shield.

21. The titration package of item 20, wherein the shield is activatedmanually by the patient.

22. The titration package of item 20, wherein the shield is automated.

23. The titration package of item 22, wherein the automated shield isactivated by the patient.

24. The titration package of item 22, wherein the needle isautomatically shielded without any action by the patient.

25. The titration package of item 22, wherein the needle is shieldedwithout any action by the patient.

26. The titration package of item 9, wherein the package furtherincludes a dose-limiting titration device.

27. The method of any of items 1-8, further comprising administration ofan analgesic or anti-inflammatory drug, or a mixture thereof.

28. The method of item 27, wherein the drug is a steroid.

29. The method of item 27, wherein the drug is a non-steroidalanti-inflammatory agent.

30. The method of item 27, wherein the drug is acetaminophen.

31. The method of item 27, wherein the drug is ibuprofen.

Examples

The compositions and processes of the present invention will be betterunderstood in connection with the following examples, which are intendedas an illustration only and not limiting of the scope of the invention.Various changes and modifications to the disclosed embodiments will beapparent to those skilled in the art and such changes and modificationsincluding, without limitation, those relating to the processes,formulations and/or methods of the invention may be made withoutdeparting from the spirit of the invention and the scope of the appendedclaims.

Avonex® was studied in a randomized, three-arm, dose-blinded,parallel-group study to determine the effect of Avonex® dose titration,administered intramuscularly, on the severity and incidence ofIFN-β_(1a)-related flu-like symptoms in healthy volunteers. The approvedtherapeutic dose of Avonex® is 30 μg weekly by IM administration.

In this blinded, parallel-group study, subjects were randomized to 1 of3 treatment arms: Group 1—no titration (weekly IM IFN-β_(1a) 30 μg for 8weeks); Group 2—fast dose titration (quarter-dose increments every weekup to 30 μg over 3 weeks, full dose to Week 8); and Group 3—slow dosetitration (quarter-dose increments every 2 weeks up to 30 μg over 6weeks, full dose to Week 8). See FIG. 1. In order to evaluate flu-likesymptoms (FLS) in a controlled condition and to avoid bias, allsubjects, regardless of symptoms, were administered prophylacticmedication (acetaminophen 650 milligrams (mg) orally within 1 hour priorto Avonex® injection, and at 4 to 6 hours, 8 to 10 hours, and 12 to 15hours following injection.)

Each week, the presence and intensity of fever, muscle aches (myalgia),chills, and fatigue symptoms were recorded at pre-injection, 4 to 6hours and 12 to 15 hours post injection. Each FLS was assigned a scorefrom 0 to 3 by the investigator as follows: 0=absent; 1=mild, did notinterfere with daily activities; 2=moderate, sufficient to interferewith daily activities; 3=severe, bed rest required. Body temperature wasrecorded to determine the presence of fever using the following scale: 0(<99.1° F.); 1 (≥99.1° F. but <100.1° F.); 2 (≥100.1° F. but <101.1°F.); 3 (≥101.1° F.). The total score (sum of the 3 symptom scores andfever score) for each of the 3 timepoints (pre-injection, 4 to 6 hours,and 12 to 15 hours) was be calculated during data analysis. For eachtimepoint, the maximum total score was 12 and the minimum total scorewas 0. A total score of 2 points or greater above the pre-injectionscore was considered positive for the presence of FLS.

A total of 234 subjects were enrolled, 78 per arm, and 195 (83%)completed the study. The majority of subjects were female (62%) and themean age was 32.9 years. Subjects in the fast and slow titration armshad significantly less severe FLS over 8 weeks than subjects infull-dose arm at 4-6 hours post injection (0.132 [P<0.001] and 0.267[P<0.001] vs 0.539) (see FIG. 2) and 12 to 15 hours post injection(0.475 [P<0.001] and 0.515 [P=0.002] vs 0.753) (see FIG. 3). Whencompared to the no titration group at 4-6 hours post injection, theincidence of FLS was significantly less for the fast titration group(odds ratio [OR]: 0.179 [0.075, 0.429], P<0.001) and the slow titrationgroup (OR: 0.414 [0.194, 0.994], P=0.023) (see FIG. 4). Similar resultswere demonstrated at 12-15 hours post injection (fast titration OR:0.469 [0.272, 0.907], P=0.006; slow titration OR: 0.562 [0.338, 0.936],P=0.027) (see FIG. 4).

The patent and scientific literature referred to herein establishes theknowledge that is available to those with skill in the art. All UnitedStates patents and published or unpublished United States patentapplications cited herein are incorporated by reference. All publishedforeign patents and patent applications cited herein are herebyincorporated by reference. All other published references, documents,manuscripts and scientific literature cited herein are herebyincorporated by reference.

While this invention has been particularly shown and described withreferences to preferred embodiments thereof, it will be understood bythose skilled in the art that various changes in form and details may bemade therein without departing from the scope of the inventionencompassed by the appended claims.

1. A combination of delivery devices and dose-limiting accessory devicesfor use in reducing the severity of flu-like symptoms associated withtreating a patient having multiple sclerosis with intramuscularlyadministered interferon-β-1a over an eight week period, wherein thecombination comprises interferon-β-1a, delivery devices anddose-limiting accessory devices for once a week intramuscularadministration to a patient having multiple sclerosis according to afirst schedule comprising: a first delivery device for intramuscularadministration of interferon-β-1a to the patient and a firstdose-limiting accessory configured to limit dispensing of the firsttitration dose from the first delivery device to 7.5 μg of theinterferon-β-1a in week one; a second delivery device for intramuscularadministration of interferon-β-1a to the patient and a seconddose-limiting accessory configured to limit dispensing of the secondtitration dose from the second delivery device to 15 μg of theinterferon-β-1a in week two; a third delivery device for intramuscularadministration of interferon-β-1a to the patient and a thirddose-limiting accessory configured to limit dispensing of the thirdtitration dose from the third delivery device to 22.5 μg of theinterferon-β-1a in week three; and a fourth delivery device forintramuscular administration of 30 μg interferon-β-1a to the patient;wherein the combination reduces severity of the flu-like symptoms at 4-6hours and at 12-15 hours after each intramuscular administration ofinterferon-β-1a throughout an eight week period which includes once aweek intramuscular administration of 30 μg of interferon-β-1a to thepatient in weeks four through eight (i) when compared to the severity ofthe flu-like symptoms at 4-6 hours and at 12-15 hours after eachintramuscular administration of interferon-β-1a in a second schedulecomprising once a week intramuscular administration of 30 μg ofinterferon-β-1a to a patient having multiple sclerosis for eight weeks;and (ii) when compared to the severity of the flu-like symptoms at 4-6hours and at 12-15 hours after each intramuscular administration ofinterferon-β-1a in a once a week intramuscular administration of themedicament to a patient having multiple sclerosis according to a thirdschedule comprising: intramuscular administration of 7.5 μg ofinterferon-β-1a to the patient in weeks one and two; intramuscularadministration of 15 μg of interferon-β-1a to the patient in weeks threeand four; intramuscular administration of 22.5 μg of interferon-β-1a tothe patient in weeks five and six; and intramuscular administration of30 μg of interferon-β-1a to the patient in weeks seven and eight.
 2. Thecombination of claim 1, further comprising vials containing theinterferon-β-1a in lyophilized form.
 3. The combination of claim 2,further comprising a vial adapter and the delivery devices are syringespre-filled with a diluent for said lyophilized interferon-β-1a.
 4. Thecombination of claim 1, wherein the delivery devices are pre-filledsyringes containing interferon-β-1a in liquid form.
 5. The combinationof claim 1, wherein the delivery device comprises an auto-injector. 6.The combination of claim 1, wherein the delivery device is needle-free.7. The combination of claim 1, wherein the delivery device is a pen. 8.The combination of claim 1, further comprising a needle stick preventiondevice.
 9. The combination of claim 1, wherein the needle-stickprevention device comprises a needle shield.
 10. The combination ofclaim 9, wherein the shield is configured to be activated manually by auser.
 11. The combination of claim 9, wherein the shield is automated.12. The combination of claim 11, wherein the automated shield isconfigured to be activated by a user.
 13. The combination of claim 11,wherein the needle is configured to be automatically shielded withoutany action by the user.